Managed care was designed to decrease the number of patients running to the emergency room for every little sniffle by making routine visits to a primary care physician a first-time option for some. However, an unusual complaint may be missed due to the managed care maze…
Case Study
A 37-year-old white male (yowm) presented to my office with severe LBP and clinical signs and symptoms consistent with a L5-S1 herniated disc. I had seen this patient on prior occasions for minor aches and pains. His symptoms were quite severe and ambulation was almost impossible. Following protocol I ordered a MRI at the local hospital to confirm the diagnosis, only to find out insurance would not pay unless his primary care physician ordered this test. My patient’s primary care physician was unavailable, so we improvised and had another primary care physician (a personal friend of mine) in his plan call and do the favor. He had the MRI and surgery within 48 hours to remove a sequestered piece of disc. This referral process took hours, all the while the patient was standing in my office immobile from pain.
Interpretation
Managed care mishap. We got lucky. This worked, but we shouldn’t have to depend on luck to care for our patients.
When Managed Care Doesn’t Work
Let’s talk about when and how managed care does not work. I understand the purpose of managed care is to control costs and make health care insurance coverage available to a greater number of people. The perception of the fee-for-service (the old system) was only those with the “good insurance” or money received good quality care. According to the insurance industry, the cure for this is managed care. As a physician, I disagree. I believe managed care only allows more consumers to have health insurance, but not necessarily greater access to health care, and in some cases the quality of care is questionable. Even with the advent of managed care, fee-for-service is still the best option for consumers who can pay. Of course, managed care advocates would argue some care is better than no care at all for those who cannot afford anything else.
When Insurance Companies Play Doctor
Health care consumers believe managed care plans enable them to receive health care that they otherwise may not have received. In truth, just the opposite is happening. In an effort to contain escalating health care costs, medical procedures are being dictated by insurance plans instead of doctor’s diagnoses. Many patients incorrectly assume that if their health care plan does not reimburse a particular procedure, then this procedure is unnecessary. Managed care may be decreasing the number of patients running to the emergency room for every sniffle by making routine visits to a primary care physician a first-time option for some. However, managed care is offering average health care for the average complaint. An unusual complaint may be missed because of the managed care maze.
Splitting the Pot
Some managed care plans present a conflict of interest for primary care doctors. These plans offer gatekeeper physicians monetary incentives on a case-by-case basis for savings to insurance companies. For instance, if you are a primary care physician a particular plan may have a $1,000 cap per patient for diagnostic testing expenditures. If you refer your patient to a specialist who orders one test which costs $800, that leaves $200 in the kitty. If a primary care physician suggests to a patient that the expensive $800 test is unnecessary and the patient forgoes the test, then $1,000 remains in the kitty. The primary care gatekeeping physician may get to keep half of what is in the kitty because the insurance company feels that they are ahead. Here’s where and why access to health care can be limited to the consumer. So, you need to let your patients know that there is a potential conflict of interest with their primary care physician.
Patients should ask insurance agents the following: How is my insurance plan set up? Does my gatekeeper have a conflict of interest? Is he or she going to be penalized for ordering health care diagnostic procedures or rewarded for restricting them? Don’t assume your patients always understand their plans.
Lack of Standards
Another mind boggler, is the fact that the insurance companies still are not standardized. From insurer to insurer, neither the forms nor payment of CPT codes are consistent. It seems as if answers to inquiries change daily, if not hourly, too. If the industry was standardized, a great deal of cost could be saved. The HMOs and PPOs have not necessarily made the insurance companies any better at resolving these inconsistencies.
To better service my patients, my office utilizes a billing service that has been in service for more than 20 years. The owner, who I’ll call Elaine, has been able to use her knowledge to help guide office staff and patients through the billing process. I also have a contact at a large metropolitan health plan provider. I’ll call her Jane. She is the clinical complaint coordinator. She handles physician and patient complaints. This is the person who answers my questions about the specifics of plans. One afternoon Jane told me, “I hate the managed care system and don’t believe it necessarily eliminates the abuses it was supposed to.” I knew I wasn’t alone.
As a whole, we, as physicians and patientsas consumersmust indicate that this policy and these terms are unacceptable. Insurers must make payment more timely. They must be more consistent. Because they are not trained health care providers, they must refrain from making health care decisions for their customers. Because insurers have not sat eye-to-eye across from a patient stating, “Mrs. Smith, we need to do this procedure, but your insurance company won’t pay for it. Are you able to pay for it?” They do not realize the full consequences of their policies. What happens when average care is given to a not-so-average case. Who suffers?s
Delilah Renegar, D.C., of Lisle, Illinois, is a 1988 graduate of The National College of Chiropractic. She has been in practice for nine years and teaches chiropractic palpation and pediatrics at The National College of Chiropractic.
